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Despite the criticism and decline in utilization, there is an extensive and growing list of research demonstrating the clinical and cost-utility of epidural procedures in managing spinal pain.

Literature in the form of randomized controlled trials (RCTs), systematic reviews, and third party cost-effectiveness studies show that injections may be useful for diagnostic purposes and pain relief. While injections fall out of our scope as chiropractors, that doesn’t mean we can deny the science and possible positive results from these procedures.

Check out this week’s blog for 5 important considerations when discussing cervical epidural steroid injections (ESI) with your patients.

Watch Dr. Steele explain how to foster a relationship with an interventional pain management physician that benefits the patient first.

1. ESI AS A DIAGNOSTIC TEST

A steroid injection can make sense for diagnostic purposes during the physical exam if the patient history justifies it.  A selective injection may help guide further treatment based on the patient’s response.  Disc herniations and age-related cervical spondylosis frequently cause cervical radiculopathy.  The C7, C6, and C8 nerve roots are the most common nerves affected in descending order of frequency. (1) ESIs may confirm a differential diagnosis, possibly leading to a specific treatment method or location.  

2. PAIN RELIEF

Cervical steroid injections can provide temporary relief when there is inflammation or damage to a nerve.  Pain relief allows a patient to re-engage in normal activities of daily living. ESI therapy only provides short term relief often between 2-3 weeks. (2) Many evidence-based chiropractors understand the importance of co-managing these cases with a local pain management physician for CHEMICAL pain symptoms during painful episodes.  Utilizing ESI’s will provide chemical relief of the affected nerve root allowing patients to engage in exercise therapy and tolerate your in-office MECHANICAL treatments. 

Chemical Pain:
  • Constant pain
  • Recent onset (traumatic or possibly insidious)
  • Cardinal signs may be present – swelling, redness, heat, tenderness
  • Lasting aggravation of pain by all movements
  • No movement found which abolishes pain
Mechanical Pain:
  • More commonly intermittent, but may be constant
  • Specific repeated movements cause a lasting reduction or abolition of pain
  • Movements in one direction may worsen symptoms, whereas movements in the other direction will improve them

3. DISABILITY

Epidural steroid injections may also help with secondary conditions or symptoms.  In a study by Persson et al., 48% of patients reported ≥50% VAS reduction in arm pain after cervical ESIs. More interesting, is that 91% of patients had improved neck disability indices (NDI). Neck disability scores measuring pain intensity, sleep, and headache had improved by the greatest magnitude. (3) 

4. DURATION

Pain relief form ESIs is quick and can sometimes last for days to months. Approximately 50% of patients experience ≥50% pain reduction at short- and intermediate-term follow-up after cervical epidural injections. (1) This procedure provides a window of opportunity to educate your patients on possible changes to their postures and activities, ultimately leading to dysfunction.  Remember, pain is a good thing! It is a warning sign indicating damage to the body.  Pain relief is not the end goal; instead use this episode of care to educate your patients on the factors that need to be changed to prevent reinjury. 

5. SIDE EFFECTS

Some patients may experience side effects. Approximately 4.8% of the patients who underwent spinal injections experienced minor and transient systemic effects. These effects were more common in patients who had undergone previous spine surgery or received a prior cervical ESI. (4) Other possible systemic effects include; facial flushing, headache, vasovagal reaction, mood change, gastrointestinal problems, and cardiovascular symptoms (5)

Getting paid is a side effect of doing a good job.

-Me ☺

Treatments typically employed to reduce pain associated with cervical radiculopathy include physical therapy, spinal manipulation, spinal traction, anti-inflammatory and neuropathic pain medications, acupuncture, epidural steroid injections, and surgical decompression. Although most cases of cervical radiculopathy eventually resolve, severe pain often prompts physician-directed interventions. (1) Epidural injections provide a window of opportunity to return a patient to regular activity or engage in exercise therapy. Most cervical radicular pains are self-resolving, but take significant time and incur disability.  In patients with cervical disc herniations, improvements in pain and function tend to occur within four to six months, and complete recovery occurs in 83% of patients within 24–36 months. (6) Many patients are not going to wait that long for healing to occur.  Chiropractors are in a unique position to recommend what we think is best for the patient without external pressures.  Sometimes best practice management may include services not performed in your office.

Establishing integrated co-management relationships benefits both patients and providers.  Our flagship clinic sees over 300 referrals each year from physicians who want to direct their patients to a conservative approach. 

Our ChiroUp subscribers already have access to resources that can dramatically enhance MD interaction and referrals — along with dozens of other marketing campaigns they can use to influence their community. 

Yeah that’s right, ChiroUp does marketing too. 

If you’re already using a program for exercise plans, or a program for reviews, or a program to track patient outcomes– whatever program it may be. Stop.

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References
  1. Conger A, Cushman DM, Speckman RA, Burnham T, Teramoto M, McCormick ZL. The effectiveness of fluoroscopically guided cervical transforaminal epidural steroid injection for the treatment of radicular pain; a systematic review and meta-analysis. Pain Medicine. 2020 Jan 1;21(1):41-54.
  2. Pinto RZ, Maher CG, Ferreira ML, Hancock M, Oliveira VC, McLachlan AJ, Koes B, Ferreira PH. Epidural corticosteroid injections in the management of sciatica: a systematic review and meta-analysis. Annals of internal medicine. 2012 Dec 18;157(12):865-77.
  3. Persson L, Anderberg L. Repetitive transforaminal steroid injections in cervical radiculopathy: A prospective outcome study including 140 patients. Evid Based Spine Care J 2012;3(3):13–20.
  4. Kang WY, Lee JW, Lee E, Kang Y, Ahn JM, Kang HS. Systemic effects of fluoroscopically guided epidural steroid injection with dexamethasone. The Korean journal of pain. 2019 Jul;32(3):178.
  5. Plastaras C, McCormick ZL, Garvan C, Macron D, Joshi A, Chimes G, et al. Adverse events associated with fluoroscopically guided lumbosacral transforaminal epidural steroid injections. Spine J. 2015;15:2157–65. doi: 10.1016/j.spinee.2015.05.034.
  6. Wong JJ, Côté P, Quesnele JJ, Stern PJ, Mior SA. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: A systematic review of the literature. Spine J 2014;14(8):1781–9.

About the Author

Dr. Brandon Steele

Dr. Brandon Steele

DC, DACO

Dr. Steele is currently in private practice at Premier Rehab in the greater St. Louis area. He began his career with a post-graduate residency at The Central Institute for Human Performance. During this unique opportunity, he was able to create and implement rehabilitation programs for members of the St. Louis Cardinals, Rams, and Blues. Dr. Steele currently lectures extensively on evidence-based treatment of musculoskeletal disorders for the University of Bridgeport’s diplomate in orthopedics program. He serves on the executive board of the Illinois Chiropractic Society. He is a Diplomate and Fellow of the Academy of Chiropractic Orthopedists (FACO). His mission in practice is to get people in and out of pain as fast as possible; then give each patient the education and rehabilitation to never see them again. Dr. Steele is also the co-founder of ChiroUp.com, a resource used around the world by practicing chiropractors and colleges.

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